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Brostrom lateral ligament reconstruction using JuggerKnot soft tissue anchor(Zimmer-Biomet)

    Overview

    Learn the Brostrom lateral ligament reconstruction using JuggerKnot soft tissue anchor(Zimmer-Biomet) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Brostrom lateral ligament reconstruction using JuggerKnot soft tissue anchor(Zimmer-Biomet) surgical procedure.
    It is estimated that, in the UK, there are approximately 7000 ankle sprains per day. 85% of these sprains will involve the anterior talo-fibular (ATFL) and calcaneo-fibular (CFL) ligaments which are the principal lateral ligament restraints. Most will resolve with little input other than basic remedies such as rest, ice, compression and elevation. In those cases that do not recover quickly, it is either because they have been subjected to repeated sprains or there is a concomitant pathology such as an osteochondral lesions of the talus, peroneal tendon tears or peroneal retinaculum injury.
    In those cases where non-operative treatment fails, surgical intervention may be necessary with the aim of restoring ankle stability by repair of the lateral ligament complex which can be done using the Zimmer Biomet JuggerKnot soft (suture) anchor. One surgical technique that has continued good results was first described by Brostrom in 1966, whereby the ATFL and CFL are imbricated, with an additional modification by Gould in 1980 which detailed additional imbrication of the inferior extensor retinaculum (IER). This technique forms the mainstay of anatomic ankle reconstruction techniques not only because of the high success rates but also because of low rates of complication such as ankle stiffness and subtalar arthritis.
    The advantage of the Zimmer Biomet JuggerKnot soft tissue anchor system is that it offers excellent pull-out strength at the bone-anchor interface with a minimal footprint in the bone.

    Indications

    Indications
    Since most acute ankle sprains will settle with basic non-operative measures, most surgeons agree that there is no need to perform an acute surgical repair of the lateral ankle ligaments.
    The role of a Brostrom-Gould procedure is in the treatment of chronic ankle instability. The textbooks describe two groups of patients with chronic ankle instability: mechanical and functional. In mechanical instability there is an excess of ankle motion beyond the physiological range. In functional instability, the range of ankle motion is deemed normal but the voluntary control of that range of motion is impaired. In reality, it is difficult to categorise patients and most patients will have a combination of both. Therefore, it is imperative that patients will have had a robust programme of physiotherapy intervention because improved voluntary control of the ankle will often be successful in treating the instability.
    Only when patients have failed to progress with targeted physiotherapy input should surgery be considered.
    Symptoms & Examination
    Patients with chronic ankle instability present with a number of symptoms. The two most common symptoms are instability and pain, but sometimes a locking sensation may be a feature. Clearly, the onset and duration of symptoms should be noted. It takes a great deal of skilled questioning of the patient to elicit the key features of both of these primary symptoms. Patients often tell you that their ankle “gives way” or that they “don’t trust” their ankle. It is important to determine when the ankle feels unstable by asking about the surfaces and camber and the activities that induce the instability. If someone only gives way on their ankle once a year when they walk on cobbled stones then surgery is not an appropriate solution. To direct questioning, pain may only occur after an episode of giving way, suggesting that it is the incompetence of the ligaments that is the prime issue. The presence of associated symptoms such as pain, swelling and a feeling of structures dislocating should be noted. Pain and swelling may be an indicator of intra-articular pathology. Pain that precedes the ankle giving way or a feeling of locking may indicate an osteo-chondral lesion. A sensation or observation of the frank dislocation of the peroneal tendons also makes patients feel unstable and this pathology will need addressing in its own right.
    It is also important to determine any factors that improve the ankle instability. For instance, patients may have tried bracing their ankle. It is worthwhile asking them to describe the braces that they have tried because there are a variety of braces that are freely available on the market. Some are not much more supportive than a sock yet others have rigid medial and lateral integral plates with a long working length to control the lever arm. Most patients will feel most stable by avoiding surfaces and activities that induce their symptoms.
    Lastly, a full history should include a detailed enquiry into the exercise regimes that have been undertaken with physiotherapists. It is not uncommon for patients to have simply been issued with an exercise sheet alone. Others will have been through a full, supervised programme with a physiotherapist involving proprioceptive training on a wobble board.
    Examination should include an assessment for signs of systemic ligamentous laxity and some surgeons will routinely apply a Beighton’s score to grade this. Knowledge of the patient’s Body Mass Index (BMI) is necessary. It is useful to watch the patient walk, noting the position of heel strike and observing any varus thrusting of the ankle. From behind, a standing assessment of the limb alignment is mandatory especially to look for a cavus foot and for various attitude of the hindfoot. Any medialisation of the centre of gravity through the ankle will put the lateral ligaments at a biomechanical disadvantage and will need to be addressed at the time of surgery. A detailed assessment of motor power within the foot and ankle is helpful especially in the presence of a cavovarus foot.
    With the patient seated, palpation may reveal tender areas that may raise the suspicion of an intra-articular pathology. The peronei may also be tender and may be subluxatable. Some patients may even be able to reproduce peroneal tendon subluxation or it may be inferred by an apprehension test. Testing for true instability is most meaningful when each specific test is compared to the contralateral side. When performing a drawer test, an absence of a firm end-point is indicative of considerable mechanical instability. Performing this test in dorsiflexion and plantar flexion is supposed to help differentiate whether or not the CFL is attenuated but I do not find this useful. Some patients who have an abnormal drawer sign may tell you that performing this manoeuvre reproduces their pain. If the talus can be tilted into varus when the foot is plantigrade, then this indicated the lateral ligaments are incompetent.
    Investigation
    Weight bearing plain radiographs are mandated. Clearly, they will demonstrate the presence of degenerative change but in terms of managing ankle instability, it is useful to specifically look for osteo-chondral lesions within the dome of the talus. It is useful to look for evidence of an avulsed piece of bone from the distal fibula not only because this suggests a previous lateral ligament injury, but also because there is some evidence to suggest that the results of a Brostrom-Gould repair are not as good in these patients. This is probably because the avulsed fragment requires excision and leaves a rent in the cuff of ligament making imbrication more difficult.
    Magnetic resonance imaging is also mandated because this will give clear imaging of osteo-chondral lesions within the ankle mortise. Ultrasound provides the most accurate way of assessing the integrity of the peroneal tendons and the retinaculum that anchors them adjacent to the fibula.
    Some surgeons find the use of stress radiographs helpful, but I have found this to be of little value in my practice with the crucial information coming from an accurate history and examination coupled with the aforementioned diagnostic imaging.
    Operative alternatives
    By and large, the role of non-anatomic procedures to restore ankle stability by tenodesing the peroneal tendons in various ways (such as Watson-Jones and Evans procedures) are largely consigned to history. Other anatomic lateral ligament reconstructive procedures that can be used are more technically challenging and involve the use of autograft or allograft tendons or synthetic ligaments. These are routed into bone tunnels positioned in the talus, fibula and calcaneus to mimic the axes of the ATFL and CFL and secured with interference screws. In the main, these are excellent options for failed Brostrom-Gould procedures, in patients with a high BMI or in those with significant hindfoot varus. Synthetic ligaments are being more widely used to augment Brostrom-Gould procedures but there are no long-term studies supporting their use. Arthroscopic Brostrom procedures have also gained some traction but they technically challenging, with a long and steep learning curve and their results are not better than open techniques with some authors reporting higher complication rates.
    Contraindications
    This operation requires the patient to be actively engaged with their treatment because the surgery is the first step in a rehabilitation programme. Patients who are incapable of making regular physiotherapy visits post-operatively should not undergo an operation. Logical contra-indications include the presence of active infection.
    Some of the contra-indications to a standard Brostrom-Gould are logical tenets of orthopaedic surgery. For instance, the procedure relies on the need for an individual to respond to proprioceptive training, therefore any neurological compromise that could affect this means that the procedure is unlikely to be successful. The classic Brostrom-Gould is contra-indicated in cases of systemic laxity. It is common sense not to perform soft tissue reconstructive procedures about a joint that is degenerate.
    Non-operative intervention
    As previously alluded to, chronic ankle instability can be well managed by sensible bracing and physiotherapy. Therefore, a multi-disciplinary team of orthotists and physiotherapists are invaluable in helping you manage your patients.

    Setup

    If I plan to perform a concurrent ankle arthroscopy and Brostrom’s procedure, then I will position the patient in a supine position primarily to cater for the arthroscopic instruments. However, in the absence of any medial intra-articular pathology, I always position my patients on their side for the Brostrom procedure with the affected side uppermost. In this position, the views afforded of the lateral ligaments are optimised and it is possible to perform the operation by being seated at the foot of the operating table. In addition, if you need to perform a lateralising calcaneal osteotomy, lying the patient in a full lateral position facilitates the surgical approach.
    I support the patient with rigid, well-padded supports positioned against the lumbo-sacral junction and anterior superior iliac spines. I place a pillow between the two legs. A thigh tourniquet and exclusion drape are required. The patient has a single dose of appropriate prophylactic antibiotics before the tourniquet is inflated.

    Operation – 1

    Examination under anaesthesia to elicit the amount of drawer needed to be corrected with the surgery.
    Before positioning the patient, I perform an examination under anaesthesia and familiarise myself with the amount of drawer that I need to stabilise compared with the normal side. I perform my drawer test by gripping the distal tibia in one hand and fixing it. With my other hand, I grip the talus and calcaneus and gently draw the hindfoot anteriorly. I am looking for the translation of the talus out of the mortise, best seen in area A, and at the same time, I am feeling for the presence or absence of an “end-point” in the draw and how firm this feels. I also apply a varus force across the talus to feel if it tilts in the mortise.

    Identify the path of the superficial peroneal nerve at the level of the ankle.I also identify the course of the superficial peroneal nerve (A) by plantarflexing the ankle, inverting the hindfoot and pulling the 4th toe into deep plantarflexion. In most individuals this nerve can be easily identified and to mark it on the skin raises the surgeon’s awareness of its proximity when performing anterior ankle arthroscopy and the Brostrom’s procedure.

    Turn the patient into the full lateral position.Note the lateral positioning of the patient with the table supports and pillows as referred to in the “Set-up” section of this case.

    Skin markings identify the anterior border of the distal fibula. This curved line forms the skin incision.The anterior border of the distal fibula is palpated and dots are marked on the skin from the level of the ankle mortise to the tip of the fibula.

    Those dots are then joined up with a continuous line and the course of the superficial peroneal nerve is also marked on the skin.

    Incise the skin and beneath the fat identify the inferior band of the extensor retinaculum. Incise it in line withe incision and preserve the layer.The skin is incised and the subdermal fat is reflected and with sharp dissection, the inferior band of the extensor retinaculum (IER) is identified and divided in line with the skin incision (A). Frequently, there are several small veins encountered that will require diathermy cauterisation. The IER plane needs careful protection as it will be imbricated as part of the Gould modification element of the procedure in the penultimate step before skin closure.

    Identify the attenuated anterior talo-fibular ligament.Sharp dissection then reveals the deeper, attenuated ATFL [A].

    Divide the anterior tala-fibular ligament in line with the incision. Extend this to visualise the calcaneo-fibular ligament.Using a scalpel, the ATFL is then divided in line with the skin incision close to the anterior border of the distal fibula. With a Langenbeck retractor placed deep to both layers, good views of the lateral dome of the talus [A] are afforded especially when the ankle is put through a range of motion.
    The calcaneofibular ligament (CFL) is also identified near the tip of the fibula [B]. It lies deep to the peroneal tendons and is not visualised in the operative photographs. In this particular case, the CFL was intact and did not require repair.
    At this stage, from the pre-operative MRI scans, if there is any known osteo-chondral lesion in the lateral talar dome, this can be debrided of loose and unstable articular cartilage and the underlying bed of the lesion can be microfractured.

    Elevate the origin of the ATFL from the fibula. Create a trough along the anterior border of the distal fibula.Using sharp dissection, the origin of the ATFL is then elevated sub-periosteally so that the curved surface of the anterior aspect of the distal fibula is exposed. In hard bone, as in this case, a high speed burr with a 4mm round head attachment is used to create a trough or groove in the bone. In softer bone, the trough can be created using a tiny osteotome and rongeurs. Either way, by exposing bleeding cancellous bone, this provides the best bed in which to insert the ligament.

    The trough exposes cancellous bone and courses along the anterior distal fibula rim (A). Care should be taken to make sure that there is no compromise to the articular surface. This trough will accept the suture anchors that will approximate the imbricated ATFL sheet. The aim is to try and re-create an interface between ligament and bone akin to Sharpey’s fibres.

    This is the JuggerKnot Short Rigid size 2 (1.45mm) anchor. The interpretation of the description of the product on the packaging is as follows: It comes pre-packed in a box containing a guide wire that drills a 1.45mm hole and the grey handled introducer incorporates the JuggerKnot suture anchor. This anchor is made of three component parts all connected together:
    1 There are two no.5 tapered needles at each end of the JuggerKnot anchor [A]. The needles are protected in a thin sheath of foam.
    2 In the middle of the length of the JuggerKnot, there is a condensation of white fabric that sits tightly in an eyelet at the end of the introducer [B](see next slide).
    3 Connecting these components is the blue MaxBraid suture. This is a no. 2 size suture made of 100% polyethylene [C]. The blue suture winds around the grey plastic body of the introducer and is secured under the white knurled plastic nut [D].


    This is a picture of the tip of the introducer after the suture has been discharged. The apex of the white suture fabric loop sits within the eyelet when loaded on the introducer.
    NB – this metal tip is not particularly sturdy meaning that it can bend if the introducer is not aligned along the guide wire track when struck with a toffee hammer.

    The anchor works by drilling a hole using the guide wire to the depth of the black line. The introducer is then placed at the opening of the drill hole and the introducer is gently tapped so that the suture is driven into the hole as far as the depth of the black line. This buries the white fabric of the suture loop deep along the guide wire track.

    The white knurled plastic nut is then undone and the two ends of the suture strands are released from underneath it. They are then unwound from the grey body. Once the sutures are free of the introducer, the introducer is removed. It is important to pull on both ends of the blue MaxBraid suture as this effectively expands the white fabric in the guide wire hole. If this cuts out then either the anchor has not been inserted sufficiently deeply or the bone quality is compromised.

    Use the 1.45mm guide wire and drill a hole in the trough to the etch mark.I tend to use three Juggerknot anchors spaced evenly along the trough. Using the 1.45mm guide wire, I drill a hole making sure that the black marker on the wire is flush with the bone surface.

    Once I am happy with the depth of the hole, I withdraw the guide wire. It is important to remember the angle at which the hole was drilled.

    Remove the guide wire and introduce the tip of the JuggerKnot anchor.The tip of the grey handled introducer is then placed at the entrance of the hole.

    Tap the anchor into place with a toffee hammer.Then the introducer is gently tapped with a toffee hammer so that the anchor is seated to the correct depth determined by the black line on the contract being flush with the bone surface. Failure to reproduce the angle at which the hole was drilled means that when tapping the anchor into place, there is a chance of bending or breaking the metal tip of the anchor rendering it useless.

    Release the suture material from the anchor.The white knurled nut is then unscrewed.

    This frees the two needles (in their white foam sheaths) and they can be unwound from the grey plastic handle.

    Remove the introducer from the anchor.Once the suture material is free of the introducer, it can be removed by traction (or occasionally it requires it to be tapped free). As mentioned previously, it is important to test that the anchor does not pull out by applying tract on both ends of the anchor.

    Repeat the process of anchor insertion dependent upon number of anchors to be used.The process is then repeated for the other two anchors. In using the JuggerKnot for any indication, I keep one of the needles sheathed in the foam to aid in identifying which one has not been passed through the tissues. I also lay the sutures neatly in a way to remember the order in which the sutures lie (from proximal to distal).

    Pass the anchor sutures into the sheet of ATFL.The Brostrom part of the procedure then commences as each suture is then passed into the ATFL layer. In order to imbricate the layer sufficiently, the needle should be passed through the layer as far as possible from the incision in the ligamentous layer. In reality, the maximal distance is 6-8mm because it becomes difficult to instrument the needle any further from the incision AND it runs the risk of catching the superficial peroneal nerve in the repair. It is also important to get a good “bite” on the tissue which can be achieved by locking suture techniques.

    Tie each anchor imbricating the ligament.I start with a double throw of a hand tied knot and ask an assistant to secure that knot with a needle holder whilst I create the second throw. This is to try and prevent knot slippage.

    This is what the Brostrom part of the procedure then looks like.

    Operation – 2

    Imbricate the inferior band of the extensor retinaculum and tie the sutures.The Gould modification then proceeds. The first layer identified in the dissection is the IER and this is imbricated using a 2/o vicryl suture, again by taking deep bites of the suture, so that a “pants over vest” repair is achieved. The idea behind the Gould modification is to stabilise the subtalar joint by tightening this fascial layer.

    It is important that this layer of the repair completely covers the non-absorbable knots of the MaxBraid because long, prominent suture ends can irritate the wound.

    Test the repair for elimination of the drawer.At this stage, I test the repair for its efficacy by repeating the drawer test. If need be, I will open up and start again if I feel that the repair has been insufficient.

    Skin closure.The skin is then closed with 3/0 monocryl taking care to evert the skin edges.

    One useful sign that the imbrication has been successful is to look at the sulcus [A] created by imbricating both the ATFL layer and the IER.

    Apply plaster of Paris slabs for temporary immobilisation of the repair.The wound is then dressed with Jelonet, gauze and orthopaedic wool in preparation for below-the-knee back and stirrup plaster of Paris slabs. This is another good reason for placing the patient in a full lateral position. With the hip in full external rotation, the knee locked in full extension and the axis of the foot vertical, the surgeon can stand on the opposite side of the operating table and the foot rests comfortably and securely on the surgeon’s belly allowing both hands to be free to apply the plaster of Paris slabs. This foot position has the added benefit of resting the operative repair.

    Each slab is applied in turn and moulded to fit leaving adequate room for swelling.

    The slabs are then secured with two crepe bandages and the position held until the cast has become sufficiently rigid.

    Post Operative

    The plaster of Paris back slabs stay in place for 2 weeks during which time, the patient is not permitted to bear weight. This is to allow the surgical wounds to settle. At the 2 week dressing appointment, the wounds are checked and, if dry and healing, the patient is then allowed to commence bearing weight using a walker boot. At this stage, the physiotherapists encourage ankle range of motion exercises that can be performed when seated at home with the boot removed. At the 6 week review, the boot is abandoned and the patient returns to normal footwear and commences a regular physiotherapy programme working on ankle and subtalar range of motion and proprioceptive training.
    Usually by 12 weeks, patients feel much more stable and are discharged from medical review but remain under the supervision of the physiotherapists. I allow patients to re-commence a graduated training regime with their sports clubs at this stage. In patients achieving the best results, they may be back playing football or rugby at 16 weeks post-surgery.
    During the first two weeks after surgery, rivaroxaban is given to prevent thrombo-embolic events. This is ceased with commencing weight bearing and ankle range of motion exercises.

    Recommended Reading

    Twenty-six-year results after Brostrom procedure for chronic lateral ankle instability. Bell SJ, Mologne TS, Sitler DF, Cox JS. Am J Sports Med 2006; 34(6): 975-978.
    This paper has the longest follow-up of the Brostrom procedure in two thirds of the original cohort of study patients. This group of patients underwent a pure Brostrom imbrication of the ligaments with no Gould modification. When required, the CFL was also repaired. Within this group, good and excellent functional results were achieved in a very high percentage of patients.
    Long-term results after modified Brostrom procedure without calcaneofibular ligament reconstruction. Lee KT, Park YU, Kim JS et al. Foot Ankle Int 2011; 32: 153-7.
    In this paper, patients were treated with a Brostrom imbrication and a Gould modification but no repair of the CFL. A high proportion of these patients were high level athletes and with a mean follow-up of more than a decade they achieved excellent outcomes.
    Arthroscopic repair of chronic lateral ankle instability. Corte-Real NM, Moreira RM. Foot Ankle Int 2009; 30(3): 213-7.
    With 2 year follow up data on a reasonable sized cohort of patients, this very honest paper details the complications from the authors’ experiences of this technique. They had equivalent successful outcomes compared to open repair techniques and the 10% complication rate consisted of the same complications seen using open repair techniques: recurrent instability, superficial peroneal nerve injury and deep vein thrombosis.

    Reference

    • orthoracle.com

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